Oral Drug Screening Request Form

To order mobile drug screening services, please fill out this form and submit.

Michelle Cline (MODSA) will then reach out to schedule with your client according to the agreed upon scheduling guidelines.

Name of Attorney / Judge - (Required)

Attorney / Judge Phone Number - (Required)

Attorney Email - (Required)

Name of Client to be tested (Donor) - (Required)

Donor's Phone Number - (Required)

Donor's Email - (Required)

Best time to reach the Donor - (Required)

Best way to contact you? - (Required)

Is there a specific location where you prefer the drug test take place? - (Select One)

Location where screening is to take place

How would you prefer to receive your client’s lab results? (Select One)

Please provide your secure portal instructions here:

Are there any further instructions or information we should be aware of?
(Purpose, potential resistance or possible difficulty reaching Donor, etc.)
(optional)